﻿<%@ Page Title="" Language="C#" MasterPageFile="~/Provider/PersonalAccident/PersonalAccident.master" AutoEventWireup="true" CodeFile="AddNewBenefitScale.aspx.cs" Inherits="Provider_PersonalAccident_AddNewBenefitScale" %>

<asp:Content ID="Content1" ContentPlaceHolderID="ContentPlaceHolder1" Runat="Server">
    <asp:ScriptManager ID="ScriptManager" runat="server"></asp:ScriptManager>
<div class="provider_inner">
        <h1>
            Benefit Scale
            <asp:Label ID="lblPAInsId" runat="server" Text="0" Visible="false"></asp:Label>
            <asp:Label ID="lblPABenifitId" runat="server" Text="0" Visible="false"></asp:Label>
        </h1>
        <fieldset>
            <asp:UpdatePanel ID="uPanelfield" runat="server">
            <ContentTemplate>
            <dl>
                <dt>
                    <label>
                        Plan Name</label></dt>
                <dd>
                    <asp:DropDownList ID="ddlPlanName" runat="server" class="text" Width="255px" 
                        AutoPostBack="true" onselectedindexchanged="ddlPlanName_SelectedIndexChanged"></asp:DropDownList>
                    <asp:RequiredFieldValidator ID="rfvPlanName" runat="server" ErrorMessage="*" ControlToValidate="ddlPlanName"
                        InitialValue="-1" ValidationGroup="addnewpains"></asp:RequiredFieldValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Policy/Plan Type</label></dt>
                <dd>
                    <asp:DropDownList ID="ddlPolicyType" runat="server" class="text" Width="255px" 
                        onselectedindexchanged="ddlPolicyType_SelectedIndexChanged" AutoPostBack="true">
                        <asp:ListItem Selected="True" Value="-1">Select</asp:ListItem>
                        <asp:ListItem Value="IND">Individual</asp:ListItem>
                        <asp:ListItem Value="INDSP">Individual & Spouse</asp:ListItem>
                        <asp:ListItem Value="INDCHD">Individual & Children</asp:ListItem>
                        <asp:ListItem Value="INDSPCHD">Individual, Spouse & Children</asp:ListItem>
                    </asp:DropDownList>
                    <asp:RequiredFieldValidator ID="rfvPolicyType" runat="server" ErrorMessage="*" ControlToValidate="ddlPolicyType"
                        InitialValue="-1" ValidationGroup="addnewpains"></asp:RequiredFieldValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Benefit Name</label></dt>
                <dd>
                    <asp:DropDownList ID="ddlBenefitName" runat="server" class="text" Width="255px" 
                        AutoPostBack="true" 
                        onselectedindexchanged="ddlBenefitName_SelectedIndexChanged"></asp:DropDownList>
                    <asp:RequiredFieldValidator ID="rfvBenefitName" runat="server" ErrorMessage="*" ControlToValidate="ddlBenefitName"
                        InitialValue="-1" ValidationGroup="addnewpains"></asp:RequiredFieldValidator>
                </dd>
            </dl>
            <asp:Panel ID="pnlPercentage" runat="server">
            <dl>
                <dt>
                    <label>
                        Death or Permanent Total Disability</label></dt>
                <dd>
                    <asp:TextBox ID="txtDeathPTD" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvDeathPTD" runat="server" ControlToValidate="txtDeathPTD"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revDeathPTD" runat="server" ControlToValidate="txtDeathPTD"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of One Limb</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossOneLimb" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossOneLimb" runat="server" ControlToValidate="txtLossOneLimb"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossOneLimb" runat="server" ControlToValidate="txtLossOneLimb"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of Two Limbs</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossTwoLimb" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossTwoLimb" runat="server" ControlToValidate="txtLossTwoLimb"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossTwoLimb" runat="server" ControlToValidate="txtLossTwoLimb"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of sight in one eye</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossShightOneeye" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossShightOneeye" runat="server" ControlToValidate="txtLossShightOneeye"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossShightOneeye" runat="server" ControlToValidate="txtLossShightOneeye"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of sight in both eyes</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossShightBotheye" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossShightBotheye" runat="server" ControlToValidate="txtLossShightBotheye"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossShightBotheye" runat="server" ControlToValidate="txtLossShightBotheye"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of hearing in one ear</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossHearingOneear" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossHearingOneear" runat="server" ControlToValidate="txtLossHearingOneear"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossHearingOneear" runat="server" ControlToValidate="txtLossHearingOneear"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of hearing in both ears</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossHearingBothear" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossHearingBothear" runat="server" ControlToValidate="txtLossHearingBothear"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossHearingBothear" runat="server" ControlToValidate="txtLossHearingBothear"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of speech</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossSpeech" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossSpeech" runat="server" ControlToValidate="txtLossSpeech"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossSpeech" runat="server" ControlToValidate="txtLossSpeech"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Total paralysis</label></dt>
                <dd>
                    <asp:TextBox ID="txtTotalParalysis" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvTotalParalysis" runat="server" ControlToValidate="txtTotalParalysis"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revTotalParalysis" runat="server" ControlToValidate="txtTotalParalysis"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Permanent bedridden</label></dt>
                <dd>
                    <asp:TextBox ID="txtPerBedridden" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvPerBedridden" runat="server" ControlToValidate="txtPerBedridden"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revPerBedridden" runat="server" ControlToValidate="txtPerBedridden"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of four fingers and thumb of right hand</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossFingRH" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossFingRH" runat="server" ControlToValidate="txtLossFingRH"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossFingRH" runat="server" ControlToValidate="txtLossFingRH"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of four fingers and thumb of left hand</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossFingLH" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossFingLH" runat="server" ControlToValidate="txtLossFingLH"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossFingLH" runat="server" ControlToValidate="txtLossFingLH"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of four fingers of one hand</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossFingOneHand" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossFingOneHand" runat="server" ControlToValidate="txtLossFingOneHand"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossFingOneHand" runat="server" ControlToValidate="txtLossFingOneHand"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of thumb (both phalanges)</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossThumbBothPhalanges" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossThumbBothPhalanges" runat="server" ControlToValidate="txtLossThumbBothPhalanges"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossThumbBothPhalanges" runat="server" ControlToValidate="txtLossThumbBothPhalanges"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of thumb (one right phalanx)</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossThumbRPhalanx" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossThumbRPhalanx" runat="server" ControlToValidate="txtLossThumbRPhalanx"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossThumbRPhalanx" runat="server" ControlToValidate="txtLossThumbRPhalanx"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of thumb (one left phalanx)</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossThumbLPhalanx" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossThumbLPhalanx" runat="server" ControlToValidate="txtLossThumbLPhalanx"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossThumbLPhalanx" runat="server" ControlToValidate="txtLossThumbLPhalanx"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of index finger (three phalanges)</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossIndexFinThreePhalanges" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossIndexFinThreePhalanges" runat="server" ControlToValidate="txtLossIndexFinThreePhalanges"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossIndexFinThreePhalanges" runat="server" ControlToValidate="txtLossIndexFinThreePhalanges"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of index finger (Two phalanges)</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossIndexFinTwoPhalanges" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossIndexFinTwoPhalanges" runat="server" ControlToValidate="txtLossIndexFinTwoPhalanges"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossIndexFinTwoPhalanges" runat="server" ControlToValidate="txtLossIndexFinTwoPhalanges"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of index finger (one phalanx)</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossIndexFinOnePhalanx" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossIndexFinOnePhalanx" runat="server" ControlToValidate="txtLossIndexFinOnePhalanx"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossIndexFinOnePhalanx" runat="server" ControlToValidate="txtLossIndexFinOnePhalanx"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of middle finger (three phalanges)</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossMidFinThreePhalanges" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossMidFinThreePhalanges" runat="server" ControlToValidate="txtLossMidFinThreePhalanges"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossMidFinThreePhalanges" runat="server" ControlToValidate="txtLossMidFinThreePhalanges"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of middle finger (two phalanges)</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossMidFinTwoPhalanges" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossMidFinTwoPhalanges" runat="server" ControlToValidate="txtLossMidFinTwoPhalanges"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossMidFinTwoPhalanges" runat="server" ControlToValidate="txtLossMidFinTwoPhalanges"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of middle finger (one phalanx)</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossMidFinOnePhalanx" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossMidFinOnePhalanx" runat="server" ControlToValidate="txtLossMidFinOnePhalanx"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossMidFinOnePhalanx" runat="server" ControlToValidate="txtLossMidFinOnePhalanx"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of ring finger (three phalanges)</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossRingFinThreePhalanges" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossRingFinThreePhalanges" runat="server" ControlToValidate="txtLossRingFinThreePhalanges"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossRingFinThreePhalanges" runat="server" ControlToValidate="txtLossRingFinThreePhalanges"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of ring finger (two phalanges)</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossRingFinTwoPhalanges" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossRingFinTwoPhalanges" runat="server" ControlToValidate="txtLossRingFinTwoPhalanges"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossRingFinTwoPhalanges" runat="server" ControlToValidate="txtLossRingFinTwoPhalanges"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of ring finger (one phalanx)</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossRingFinOnePhalanx" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossRingFinOnePhalanx" runat="server" ControlToValidate="txtLossRingFinOnePhalanx"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossRingFinOnePhalanx" runat="server" ControlToValidate="txtLossRingFinOnePhalanx"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of little finger (three phalanges)</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossLitFinThreePhalanges" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossLitFinThreePhalanges" runat="server" ControlToValidate="txtLossLitFinThreePhalanges"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossLitFinThreePhalanges" runat="server" ControlToValidate="txtLossLitFinThreePhalanges"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of little finger (two phalanges)</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossLitFinTwoPhalanges" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossLitFinTwoPhalanges" runat="server" ControlToValidate="txtLossLitFinTwoPhalanges"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossLitFinTwoPhalanges" runat="server" ControlToValidate="txtLossLitFinTwoPhalanges"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of little finger (one phalanx)</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossLitFinOnePhalanx" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossLitFinOnePhalanx" runat="server" ControlToValidate="txtLossLitFinOnePhalanx"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossLitFinOnePhalanx" runat="server" ControlToValidate="txtLossLitFinOnePhalanx"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of all toes of one foot</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossAllToesOneFoot" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossAllToesOneFoot" runat="server" ControlToValidate="txtLossAllToesOneFoot"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossAllToesOneFoot" runat="server" ControlToValidate="txtLossAllToesOneFoot"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of great toe (two phalanges)</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossGToeTwoPhalanges" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossGToeTwoPhalanges" runat="server" ControlToValidate="txtLossGToeTwoPhalanges"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossGToeTwoPhalanges" runat="server" ControlToValidate="txtLossGToeTwoPhalanges"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of great toe (one phalanx)</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossGToeOnePhalanx" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossGToeOnePhalanx" runat="server" ControlToValidate="txtLossGToeOnePhalanx"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossGToeOnePhalanx" runat="server" ControlToValidate="txtLossGToeOnePhalanx"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of other toe (one or more phalanges)</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossOToeOneMorePhalanges" runat="server" MaxLength="20" Width="150px"></asp:TextBox>%
                    <asp:RequiredFieldValidator ID="rfvLossOToeOneMorePhalanges" runat="server" ControlToValidate="txtLossOToeOneMorePhalanges"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossOToeOneMorePhalanges" runat="server" ControlToValidate="txtLossOToeOneMorePhalanges"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        3rd degree burns</label></dt>
                <dd>
                    <asp:TextBox ID="txtThirdDegreeBurn" runat="server" MaxLength="20" Width="150px"></asp:TextBox>
                    <asp:RequiredFieldValidator ID="rfvThirdDegreeBurn" runat="server" ControlToValidate="txtThirdDegreeBurn"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                </dd>
            </dl>
            </asp:Panel>
            
            <asp:Panel ID="pnlAmount" runat="server">
            <dl>
                <dt>
                    <label>
                        Death or Permanent Total Disability</label></dt>
                <dd>
                    <asp:TextBox ID="txtDeathPTDCash" runat="server" MaxLength="20" Width="150px"></asp:TextBox>
                    <asp:RequiredFieldValidator ID="rfvDeathPTDCash" runat="server" ControlToValidate="txtDeathPTDCash"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revDeathPTDCash" runat="server" ControlToValidate="txtDeathPTDCash"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Permanent Total paralysis</label></dt>
                <dd>
                    <asp:TextBox ID="txtTotalParalysisCash" runat="server" MaxLength="20" Width="150px"></asp:TextBox>
                    <asp:RequiredFieldValidator ID="rfvTotalParalysisCash" runat="server" ControlToValidate="txtTotalParalysisCash"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revTotalParalysisCash" runat="server" ControlToValidate="txtTotalParalysisCash"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of sight in both eyes or use of both hands or both feet or combination of these</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossShightBotheyeCash" runat="server" MaxLength="20" Width="150px"></asp:TextBox>
                    <asp:RequiredFieldValidator ID="rfvLossShightBotheyeCash" runat="server" ControlToValidate="txtLossShightBotheyeCash"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossShightBotheyeCash" runat="server" ControlToValidate="txtLossShightBotheyeCash"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Permanent Total Loss of speech</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossSpeechCash" runat="server" MaxLength="20" Width="150px"></asp:TextBox>
                    <asp:RequiredFieldValidator ID="rfvLossSpeechCash" runat="server" ControlToValidate="txtLossSpeechCash"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossSpeechCash" runat="server" ControlToValidate="txtLossSpeechCash"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of hearing in both ears</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossHearingBothearCash" runat="server" MaxLength="20" Width="150px"></asp:TextBox>
                    <asp:RequiredFieldValidator ID="rfvLossHearingBothearCash" runat="server" ControlToValidate="txtLossHearingBothearCash"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossHearingBothearCash" runat="server" ControlToValidate="txtLossHearingBothearCash"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of sight of one eye or use of one limb</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossShightOneeyeCash" runat="server" MaxLength="20" Width="150px"></asp:TextBox>
                    <asp:RequiredFieldValidator ID="rfvLossShightOneeyeCash" runat="server" ControlToValidate="txtLossShightOneeyeCash"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossShightOneeyeCash" runat="server" ControlToValidate="txtLossShightOneeyeCash"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of hearing in one ear</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossHearingOneearCash" runat="server" MaxLength="20" Width="150px"></asp:TextBox>
                    <asp:RequiredFieldValidator ID="rfvLossHearingOneearCash" runat="server" ControlToValidate="txtLossHearingOneearCash"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossHearingOneearCash" runat="server" ControlToValidate="txtLossHearingOneearCash"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Total Loss of use of a shoulder, elbow, hip, knee,ankle or wrist</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossSEHKAWCash" runat="server" MaxLength="20" Width="150px"></asp:TextBox>
                    <asp:RequiredFieldValidator ID="rfvLossSEHKAWCash" runat="server" ControlToValidate="txtLossSEHKAWCash"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossSEHKAWCash" runat="server" ControlToValidate="txtLossSEHKAWCash"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of One thumb</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossOneThumbCash" runat="server" MaxLength="20" Width="150px"></asp:TextBox>
                    <asp:RequiredFieldValidator ID="rfvLossOneThumbCash" runat="server" ControlToValidate="txtLossOneThumbCash"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossOneThumbCash" runat="server" ControlToValidate="txtLossOneThumbCash"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Loss of One forefinger</label></dt>
                <dd>
                    <asp:TextBox ID="txtLossOneforefingerCash" runat="server" MaxLength="20" Width="150px"></asp:TextBox>
                    <asp:RequiredFieldValidator ID="rfvLossOneforefingerCash" runat="server" ControlToValidate="txtLossOneforefingerCash"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revLossOneforefingerCash" runat="server" ControlToValidate="txtLossOneforefingerCash"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Any other finger or one big toe</label></dt>
                <dd>
                    <asp:TextBox ID="txtOthFingerOnebigtoeCash" runat="server" MaxLength="20" Width="150px"></asp:TextBox>
                    <asp:RequiredFieldValidator ID="rfvOthFingerOnebigtoeCash" runat="server" ControlToValidate="txtOthFingerOnebigtoeCash"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revOthFingerOnebigtoeCash" runat="server" ControlToValidate="txtOthFingerOnebigtoeCash"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            <dl>
                <dt>
                    <label>
                        Any other toe</label></dt>
                <dd>
                    <asp:TextBox ID="txtAnyOthertoeCash" runat="server" MaxLength="20" Width="150px"></asp:TextBox>
                    <asp:RequiredFieldValidator ID="rfvAnyOthertoeCash" runat="server" ControlToValidate="txtAnyOthertoeCash"
                        ErrorMessage="*" ValidationGroup="addnewpains">*</asp:RequiredFieldValidator>
                    <asp:RegularExpressionValidator ID="revAnyOthertoeCash" runat="server" ControlToValidate="txtAnyOthertoeCash"
                        ErrorMessage="Enter Number value." ValidationExpression="^[0-9]+(\[0-9]{1,2})?$" ValidationGroup="addnewpains"></asp:RegularExpressionValidator>
                </dd>
            </dl>
            </asp:Panel>
            <dl>
                <dt>
                    <label>
                        Status</label></dt>
                <dd>
                    <asp:CheckBox ID="chkStatus" runat="server" />
                </dd>
            </dl>
            </ContentTemplate>
            </asp:UpdatePanel>
        </fieldset>
        <fieldset class="action">
            <asp:UpdatePanel ID="uPanelaction" runat="server">
            <ContentTemplate>
            <asp:ImageButton OnClientClick="javascript:return confirm('Are you sure to go back?');"
                ID="ibtBack" runat="server" CssClass="left_btn" 
                    ImageUrl="~/Provider/images/buttons/back1.gif" onclick="ibtBack_Click" />
            <asp:ImageButton ID="ibtSubmit" CssClass="float_btn" ValidationGroup="addnewpains"
                runat="server" ImageUrl="~/Provider/images/buttons/submit1.gif" 
                    onclick="ibtSubmit_Click" />
            <asp:ImageButton ID="btnNew" CssClass="floatnext_btn" OnClientClick="return confirm('Are you sure to clear form?');" 
                runat="server" ImageUrl="~/Provider/images/buttons/new1.gif" 
                    onclick="btnNew_Click" />
            <%--<asp:ImageButton ID="btnDelete" CssClass="floatnext_btn" OnClientClick="return confirm('Are you sure you want to remove this record?');" 
                runat="server" ImageUrl="~/Provider/images/buttons/delete1.gif" />--%>
            </ContentTemplate>
            </asp:UpdatePanel>
        </fieldset>
        <asp:Label ID="lblMessage" runat="server" CssClass="successmsg" Text=""></asp:Label>
    </div>
</asp:Content>

